Total Health Environment

Saturday, August 27, 2011

Bedsore is an old fashioned word and the idea that it’s only a problem for long term care facilities and ICUs is an old fashioned idea. A study to be released in the Annals of Emergency Medicine highlights the fact that pressure ulcers can start even in the ER. Pham et al. found that pressure redistribution foam mattresses are a highly cost effective means of preventing pressure sores for elderly patients treated in the Emergency Department. The focus on elderly patients is germane because they are at higher risk, especially if they suffer from poor nutrition, and or, incontinence. Putting these patients on the pressure redistribution mattresses cost as little as 30 cents per patient and saved the hospital much more. The finding is surprising since patients aren’t expected to stay long in ERs. But as little as one hour on an unyielding mattress or stretcher can damage the skin of some patients.

Like most people, I hadn't spent a lot of time thinking about pressure sores. They aren't mentioned much by researchers or by the press. I've learned this week that they cause much more suffering than their under-the-radar status would suggest. For patients and their loved ones ulcers are painful. Some of that suffering, it seems to me though, comes from the general belief that pressure sores are entirely unnecessary. And the public doesn't get that idea out of the blue. The Center for Medicare and Medicaid Services considers pressure sores to be HACs (hospital acquired conditions) that is, entirely preventable and has refused to reimburse for treating them since 2008. And "pressure" to prevent them has climbed even further since New Jersey passed a law in 2009 allowing the state to release hospital specific data on fourteen medical mistakes. It includes pressure ulcers on that list. But is this really fair? Is every pressure sore avoidable? The research just doesn't support that conclusion.

Now don't get me wrong. I'm not suggesting that high rates of sores aren't a sign of poor care, obviously they are. And I'm not saying that there's not room for improvement, there is, plenty of room. The 2008-2009 International Pressure Ulcer Prevalence Survey gives a good general overview of the problem. In the US they found that 5 percent of all patients in acute care facilities acquired ulcers. Long-term care, had higher rates. The National Pressure Ulcer Long-term Care Study (NPULS) reported that in 2002 an average of 9.8 percent of residents had them. But the idea that pressure sores are "never events" things that wouldn't occur without someone making a mistake, is cruel. It makes patients feel worse and puts the blame on the care institution, (essentially the nurses) when the real culprit is the illness itself.

Even the best regimen can't fully prevent sores. At least one Egyptian mummy has been found with pressure ulcers,even though one presumes the person was tended by slaves. Added to the general stress that being bed bound puts on skin is the fact that contemporary medicine requires so many patients be hooked up to lines and tubes, especially in intensive care. Ten percent of ulcers are associated with such devices. And even for patients in less intensive settings, being bed bound is associated with some risk. Tom DeFloor, Head of the Ghent University Nursing Science Unit, did a series of randomized, controlled studies looking for the optimal way to manage immobile patients and prevent pressure sores. In 2007 he compared 237 nursing home residents who were repositioned every four, three or two hours. The best outcome came when patients were turned every four hours. Moving them twice as often didn't actually improve results. (International Journal of Nursing Studies 48 (2011) 787–79).

The most striking thing about this study was that even the best routine didn't take the number of pressure sores to zero. The best they could manage was about 3 percent prevalence rate. In another randomized, controlled study Professor DeFloor found that foam pressure redistribution mattresses were just as effective at preventing sores as alternating pressure mattresses. This is excellent news because alternating pressure mattresses are much more expensive. (IBID.)

If every patient who needs it is put on a foam pressure distribution mattress the financial savings is likely to be considerable. In its 2010 Patient Safety in American Hospitals Study Healthgrades estimated that pressure ulcers alone added 2.6 billion in added costs between 2006 and 2008. The British National Health Service estimated that a single severe sore can take three months to heal and cost 40,000 pounds (64,859 dollars). The mattresses that patients lie on are the most direct experience of the therapeutic environment that they have. Luckily they are a simple and relatively inexpensive element to change for the better.

For those not familiar with the term, microbiomes are the tiny ecosystems of microbes and other little critters that live on and in each of us. There are an estimated 100 trillion microbes now going about their business in four major biomes: the mouth and gastrointestinal tracts, the respiratory system, the urogenital systems and the skin. Microbes are so important to our ability to function that microbiologists are proposing to call us all "superorganisms," that is, symbiants of us and our bacteria. There has been so much interest in the microbiome that the National Institute of Health has set up the Human Microbiome Project to study them. We all learned in high school that microorganisms break down complex carbohydrates and help us to digest our Cheerios, but systems biologists are just now starting to unwind the much more complex ways that these organisms keep us going. Early results indicate that bacteria affect the way some toxins are introduced into our systems. Other studies now in the pipeline are looking at how disturbances in our intestinal biomes may be implicated in diseases such as acne, Crohn's disease, and obesity.

Monday, August 8, 2011

In this post I thought I’d take a detour from the usual practical focus of this blog and discuss some of the deep background thinking that social scientists draw on when they study the built environment. The idea that health care delivery takes place within the built environment is the starting place for this blog's project, which is to bring insights from research in the social sciences to health improvement. Why the social sciences? Because fields like architecture, geography, history and anthropology have been studying the way we interact with our environment for at least a century now. And the same tools they've developed for looking at the macro-environment (cities, regions, and nations) can also be used to study the micro-environment (hospitals, clinics, and offices).

It is an obvious truth that just as we affect our environment, it also affects us. Yet, for much of the western intellectual tradition we have preferred to focus on our power to change the world, less on what it is doing to us. As far back as to Plato’s musings on the “just city,” the focus has been on the best way to do things. In The Republic, Plato wrote about creating an environment with good laws and law-abiding citizens. He didn’t dwell much on the physical aspects of the city. He hardly touched on the fact that city life changes its inhabitants. So even going as far back as the Socratic tradition we have been fascinated with what we can to our surroundings, less interested in what they do to us.

An article in the most recent issue of the Scandinavian Journal of Public Health, [ 2011; 39(Suppl 7): 147–152.] highlighted the fact that the physical and psychosocial elements of the work environment both contribute to employees taking long-term leave due to disability and injury. My reading of this study is that although it is set in Denmark and doesn’t look at health care settings specifically, it has useful information that can be applied to health care settings. The things that injured workers and made them sick were made worse by management styles that made them uncomfortable. Conversely, workers coped better with difficult physical challenges when they felt better about the emotional surroundings they were in.

The obvious point here is that if changing health care environments is to become part of the way we improve health care delivery, then we have to consider both the physical environment and the psychosocial environment. This study provides some evidence that they are elements in interaction with each other.